Provider Demographics
NPI:1598232209
Name:HOLLIST, TONYA (LCSW)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:HOLLIST
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 S RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:SUGAR CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83448-5072
Mailing Address - Country:US
Mailing Address - Phone:208-359-0519
Mailing Address - Fax:208-233-2178
Practice Address - Street 1:1223 S RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:SUGAR CITY
Practice Address - State:ID
Practice Address - Zip Code:83448-5072
Practice Address - Country:US
Practice Address - Phone:208-359-0519
Practice Address - Fax:208-233-2178
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW35094104100000X
IDLCSW-381811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker